Bottom Line:
By searching for "Central line malposition" and then for "Central venous catheters intravascular malposition," we found 178 articles written in English.Of those, we found that 39 were relevant to our objectives and included them in our review.Although plain chest radiography is the standard imaging modality for confirming catheter tip location, signs and symptoms of CVC malpositioning even in presence of normal or inconclusive conventional radiography findings should prompt the use of additional diagnostic methods to confirm or rule out CVC malpositioning.

ABSTRACTDespite the level of skill of the operator and the use of ultrasound guidance, central venous catheter (CVC) placement can result in CVC malpositioning, an unintended placement of the catheter tip in an inadequate vessel. CVC malpositioning is not a complication of central line insertion; however, undiagnosed CVC malpositioning can be associated with significant morbidity and mortality. The objectives of this review were to describe factors associated with intravascular malpositioning of CVCs inserted via the neck and chest and to offer ways of preventing, identifying, and correcting such malpositioning. A literature search of PubMed, Cochrane Library, and MD Consult was performed in June 2014. By searching for "Central line malposition" and then for "Central venous catheters intravascular malposition," we found 178 articles written in English. Of those, we found that 39 were relevant to our objectives and included them in our review. According to those articles, intravascular CVC malpositioning is associated with the presence of congenital and acquired anatomical variants, catheter insertion in left thoracic venous system, inappropriate bevel orientation upon needle insertion, and patient's body habitus variants. Although plain chest radiography is the standard imaging modality for confirming catheter tip location, signs and symptoms of CVC malpositioning even in presence of normal or inconclusive conventional radiography findings should prompt the use of additional diagnostic methods to confirm or rule out CVC malpositioning. With very few exceptions, the recommendation in cases of intravascular CVC malpositioning is to remove and relocate the catheter. Knowing the mechanisms of CVC malpositioning and how to prevent, identify, and correct CVC malpositioning could decrease harm to patients with this condition.

f5-wjem-16-658: Portable chest radiograph showing mild cardiomegaly and bilateral basal lung opacities. A right internal jugular central venous catheter is shown with its tip apparently located at the superior vena cava. The emergency physician initially read the radiograph as showing the catheter as “adequately positioned.” Poor blood return was observed from the ports during placement. Chest burning pain was present during a normal saline infusion.

Mentions:
Undoubtedly, the 2D projections produced by conventional radiography, in contrast to those of computed tomography (CT), have limitations; for instance, the anatomical proximity of vessels to other structures can obscure whether the distal section of the catheter is in the intended location. If the CVC placement appears atypical on an anterior-posterior chest radiograph, then a lateral radiograph may be helpful. If there is still uncertainty, injecting a small amount of contrast material through the catheter during conventional radiography or performing CT may be necessary for precise radiographic localization.35 For example, when a right internal jugular approach is used, the tip of the catheter may occasionally be malpositioned in the internal mammary vein. Anatomically, the internal mammary vein originates from the brachiocephalic vein, which overlies the SVC and travels along the posterior aspect of the anterior chest wall.36 Thus, a catheter tip in the right internal mammary vein may appear to be within the SVC on a standard anterior-posterior chest radiograph (Figure 5, 6). CT, although expensive and impractical for routine use, can provide more definitive information than conventional radiography and is very useful for guiding the management of complications of CVC placement.

f5-wjem-16-658: Portable chest radiograph showing mild cardiomegaly and bilateral basal lung opacities. A right internal jugular central venous catheter is shown with its tip apparently located at the superior vena cava. The emergency physician initially read the radiograph as showing the catheter as “adequately positioned.” Poor blood return was observed from the ports during placement. Chest burning pain was present during a normal saline infusion.

Mentions:
Undoubtedly, the 2D projections produced by conventional radiography, in contrast to those of computed tomography (CT), have limitations; for instance, the anatomical proximity of vessels to other structures can obscure whether the distal section of the catheter is in the intended location. If the CVC placement appears atypical on an anterior-posterior chest radiograph, then a lateral radiograph may be helpful. If there is still uncertainty, injecting a small amount of contrast material through the catheter during conventional radiography or performing CT may be necessary for precise radiographic localization.35 For example, when a right internal jugular approach is used, the tip of the catheter may occasionally be malpositioned in the internal mammary vein. Anatomically, the internal mammary vein originates from the brachiocephalic vein, which overlies the SVC and travels along the posterior aspect of the anterior chest wall.36 Thus, a catheter tip in the right internal mammary vein may appear to be within the SVC on a standard anterior-posterior chest radiograph (Figure 5, 6). CT, although expensive and impractical for routine use, can provide more definitive information than conventional radiography and is very useful for guiding the management of complications of CVC placement.

Bottom Line:
By searching for "Central line malposition" and then for "Central venous catheters intravascular malposition," we found 178 articles written in English.Of those, we found that 39 were relevant to our objectives and included them in our review.Although plain chest radiography is the standard imaging modality for confirming catheter tip location, signs and symptoms of CVC malpositioning even in presence of normal or inconclusive conventional radiography findings should prompt the use of additional diagnostic methods to confirm or rule out CVC malpositioning.

ABSTRACTDespite the level of skill of the operator and the use of ultrasound guidance, central venous catheter (CVC) placement can result in CVC malpositioning, an unintended placement of the catheter tip in an inadequate vessel. CVC malpositioning is not a complication of central line insertion; however, undiagnosed CVC malpositioning can be associated with significant morbidity and mortality. The objectives of this review were to describe factors associated with intravascular malpositioning of CVCs inserted via the neck and chest and to offer ways of preventing, identifying, and correcting such malpositioning. A literature search of PubMed, Cochrane Library, and MD Consult was performed in June 2014. By searching for "Central line malposition" and then for "Central venous catheters intravascular malposition," we found 178 articles written in English. Of those, we found that 39 were relevant to our objectives and included them in our review. According to those articles, intravascular CVC malpositioning is associated with the presence of congenital and acquired anatomical variants, catheter insertion in left thoracic venous system, inappropriate bevel orientation upon needle insertion, and patient's body habitus variants. Although plain chest radiography is the standard imaging modality for confirming catheter tip location, signs and symptoms of CVC malpositioning even in presence of normal or inconclusive conventional radiography findings should prompt the use of additional diagnostic methods to confirm or rule out CVC malpositioning. With very few exceptions, the recommendation in cases of intravascular CVC malpositioning is to remove and relocate the catheter. Knowing the mechanisms of CVC malpositioning and how to prevent, identify, and correct CVC malpositioning could decrease harm to patients with this condition.